Consensus statement
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published online only. To view
please visit the journal online
(http://d​ x.​doi.o​ rg/​10.​1136/​
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For numbered affiliations see
end of article.
Correspondence to
Dr Jackie L Whittaker, Faculty
of Rehabilitation Medicine,
University of Alberta, Edmonton,
AB T6G 2G4, Canada;
j​ whittak@​ualberta.c​ a
Accepted 25 March 2019
© Author(s) (or their
employer(s)) 2019. Re-use
permitted under CC BY.
Published by BMJ.
To cite: Whittaker JL,
Ellis R, Hodges PW, et al.
Br J Sports Med Epub ahead
of print: [please include Day
Month Year]. doi:10.1136/
bjsports-2018-100193
Imaging with ultrasound in physical therapy: What is
the PT’s scope of practice? A competency-based
educational model and training recommendations
Jackie L Whittaker,‍ ‍ 1 Richard Ellis,2 Paul William Hodges,‍ ‍ 3 Cliona OSullivan,4
Julie Hides,5 Samuel Fernandez-Carnero,6 Jose Luis Arias-Buria,7 Deydre S Teyhen,8
Maria J Stokes9
Abstract
Physical therapists employ ultrasound (US) imaging
technology for a broad range of clinical and research
purposes. Despite this, few physical therapy regulatory
bodies guide the use of US imaging, and there are
limited continuing education opportunities for physical
therapists to become proficient in using US within
their professional scope of practice. Here, we (i) outline
the current status of US use by physical therapists; (ii)
define and describe four broad categories of physical
therapy US applications (ie, rehabilitation, diagnostic,
intervention and research US); (iii) discuss how US
use relates to the scope of high value physical therapy
practice and (iv) propose a broad framework for a
competency-based education model for training physical
therapists in US. This paper only discusses US imaging—
not ’therapeutic’ US. Thus, ’imaging’ is implicit anywhere
the term ’ultrasound’ is used.
Background
Many physical therapists embrace ultrasound (US)
imaging as a means to deliver precise and person-
alised rehabilitation. Since the first published use
of US by physical therapists (1980),1–5 there have
been three notable milestones in the evolution of
US use by physical therapists; a series of commen-
taries6–8 and original research published after the
first International Symposium on Rehabilitative
Ultrasound Imaging (RUSI; hosted by the US Army-
Baylor University Doctoral Programme in Phys-
ical Therapy, Fort Sam Houston, Texas, 2006),9 a
networking session at the International Federation
of Orthopaedic Manipulative Physical Therapists
conference (Quebec City, Canada, 2012),10 and
a second (although not affiliated) international
symposium hosted by the Universidad Francisco
de Vitoria and the Spanish Society of Ultrasound
in Physiotherapy (Madrid, Spain, 2016).11 Despite
these efforts, there remains considerable confu-
sion and inconsistencies in terminology associated
with physical therapist use of US due, in part, to
the diversity of manners in which US is used across
the profession. It is also clear that previously iden-
tified gaps related to scope of practice (a statement
describing physical therapy within the context of the
regulatory environment and the evidence base for
practice within a jurisdiction. Scopes of practices are
dynamic and evolving in accordance with changes
Whittaker JL, et al. Br J Sports Med 2019;0:1–7. doi:10.1136/bjsports-2018-100193
in the evidence base, policy and needs of service
users)12 and specialised training are growing.
At the time of the 2006 symposium, the majority
of reported uses of US by physical therapists involved
the evaluation of muscle structure (morphology)
and function, or as a source of biofeedback to aid
rehabilitation of neuromuscular control. The term
RUSI was coined to encompass these applications,
and along with a definition (see below) an accom-
panying visual representation (figure 1) of how the
practice of RUSI fits into the larger field of medical
US was developed.
Since 2006, three additional distinct categories
of physical therapist use of US beyond RUSI have
been identified. These applications include the
following: diagnosing and monitoring pathology
(diagnostic US); guiding percutaneous procedures
involving ‘dry’ (eg, acupuncture) or ‘wet’ (eg, injec-
tion) needles (interventional US); and undertaking
research (research US; see figure 2).
The three clinical categories (ie, rehabilitative,
diagnostic and interventional US) of US use fall
under the umbrella of ‘Point-of-Care Ultrasound’
defined as an ultrasound examination performed
by a qualified healthcare practitioner, usually as
an adjunct to a physical examination, to clarify
uncertain findings, or provide image guidance that
improves the success and safety of procedures in the
acute care setting, particularly when time saving
for diagnosis or treatment is critical.13 Point-of-care
contrasts US evaluations performed in a dedicated
imaging facility, or department, in a consultative
process between the treating healthcare practitioner
and a consulting imaging specialist. In the physical
therapy context, point-of-care US can be defined
as a form of examination using US undertaken in a
clinical practice setting with the intent of clarifying
uncertain clinical examination findings to enhance
the quality and effectiveness of a physical therapy
intervention. Given that physical therapy point-of-
care US examinations fall within the scope of phys-
ical therapy practice and competence (knowledge,
skills and abilities) of the examining therapist (as
per the regulations of their jurisdiction), it is essen-
tial that it is understood that they are performed
to direct a physical therapy intervention, not to
provide a medical diagnosis or direct medical
treatment.
Below, we define and describe the four broad
categories of physical therapy US applications,
discuss implications of the use of US by physical
   1
 Consensus statement
Figure 1  A visual representation of how the practice of RUSI evolved to fit into the larger field of medical us in 2006.1 12Reproduced with
permission from the J Orthop sports Phys ther.
therapists on scope of practice and training, and propose a broad
framework for a competency-based education model for training
physical therapists in US use.
Uses of US by physical therapists
This section proposes definitions and provides descriptions
and examples of each of the four broad categories of physical
therapy US applications outlined in figure 2.
Rehabilitative US imaging
The most common uses of US by physical therapists reported in
the literature fall within the realm of RUSI and have involved
studies of the musculoskeletal system in a variety of settings
(eg, sports medicine, orthopaedics, occupational, respiratory
and pelvic health). Rehabilitative US was originally defined
as a procedure used by physical therapists to evaluate muscle
and related soft tissue morphology and function during exercise
and physical tasks…and to assist in the application of thera-
peutic interventions aimed at improving neuromuscular func-
tion.9 This includes measuring muscle morphology (eg, length,
thickness, diameter, cross-sectional area, volume, fascicle
length and penation angle)14; changes or differences in muscle
morphology over time (eg, with ageing),15 between groups of
people16 or with events (eg, contraction,17 injury,18 surgery,19
exposure to microgravity20; assessing the impact of muscle
contraction on adjacent structures (movement and deforma-
tion of fascia,21 nerve,22 linea alba23 and visceral organs such as
the bladder8 and urethra24; evaluating muscle composition25;
and providing biofeedback.26 In the context of musculoskel-
etal and sports physical therapy, RUSI has been used to assess
trunk muscle size and contraction to screen for injury risk,27 28
provide feedback and measure changes in muscle size as a
2 Whittaker JL, et al. Br J Sports Med 2019;0:1–7. doi:10.1136/bjsports-2018-100193
Br J Sports Med: first published as 10.1136/bjsports-2018-100193 on 25 April 2019. Downloaded from http://bjsm.bmj.com/ on October 10, 2019 by guest. Protected by copyright.
result of injury prevention programmes29 or in response to
conditioning30 or therapeutic interventions.31 In the context of
pelvic health, RUSI has been used to understand,8 predict32 33
and manage urinary incontinence.34
Diagnostic US imaging
Diagnostic US involves examining the effects of injury, lesion
or disease on joint surfaces, muscle, tendon, ligament, bursa,
vessels, nerves and solid visceral organs.35 Traditionally, these
applications have fallen under the scope of a consulting imaging
specialist (ie, radiologist or sonographer). Given that US is
the most cost-effective, safe and rapid method of obtaining
static and real-time images, many healthcare professions have
embraced the technology for point-of-care applications. In
the context of physical therapy, diagnostic US has been used
to identify tendon abnormalities, to screen for tendinopathy
risk,36 and assess humeral torsion or acromiohumeral distance
in persons with rotator cuff pathology,14 haemarthrosis within
the joints of persons with haemophilia,37 38 nerve excursion in
entrapment neuropathy39 or ligament integrity after injury40
to inform rehabilitation. Although many physical therapists
are appropriately trained in point-of-care diagnostic US, this
application may be the most controversial given the poten-
tial overlap with other healthcare practitioners. A recent
New Zealand survey highlighted that many physical thera-
pists report confusion regarding their scope for diagnostic US
applications.41
Interventional US imaging
Interventional US involves using gray-scale brightness-mode
(b-mode) US to accurately, efficiently and safely guide ‘dry’ and
‘wet’ needles for a variety of invasive interventions including

Figure 2  Current categories of US imaging use by physical therapists. US, ultrasound
acupuncture, dry needling, percutaneous electrolysis, injec-
tion or aspiration. US-guided needling and injections have
been shown to be more accurate and efficacious than land-
mark-guided injections.42 Although physical therapy practice
acts vary globally, in regions where therapists are allowed to
use dry and wet needles, interventional US has been employed
to safely guide dry needles for acupuncture,43 trigger point
‘release’,44 and percutaneous electrolysis (ie, application
of mechanical stimulation and electric current through an
acupuncture needle theorised to provide controlled micro-
trauma to stimulate tissue repair).45 46
Research US imaging
US is used in basic, applied and clinical research that aims to
inform physical therapy practice. For example, US has been
used to improve our understanding of the impact of pain and
injury on motor control47 and muscle morphology,18 and the
relationship between motor control and function,48 to deter-
mine which patients may benefit from a specific treatment
approach,31 and to enhance motor learning and treatment
efficacy via augmented feedback.49 More sophisticated appli-
cations of US have been used to elucidate the mechanisms
underlying dry needling techniques,50 measure the excursion
of nerves with movement,51 assess the biomechanical parame-
ters (ie, stiffness) of soft tissues52 53 and how this is changed by
treatment,54 the dynamics of pelvic floor muscle contraction,24
and effectiveness of physical therapy interventions.55 Similar
to image-guided interventions, US has been used for many
years to guide insertion of intramuscular electromyography
Whittaker JL, et al. Br J Sports Med 2019;0:1–7. doi:10.1136/bjsports-2018-100193
Consensus statement
Br J Sports Med: first published as 10.1136/bjsports-2018-100193 on 25 April 2019. Downloaded from http://bjsm.bmj.com/ on October 10, 2019 by guest. Protected by copyright.
electrodes into muscles that are deep,48 small56 or associated
with high risk (eg, diaphragm.57 Beyond these applications,
there is a large body of literature assessing the reliability
and validity of US for examining various muscles,58–61 and
nerves,22 as well as the application of US into physical therapy
practice.62
US technologies and display modes
It is important to note that within each of the four catego-
ries of physical therapy US applications, a variety of US-based
imaging techniques can be used depending on the clinical or
research goal. For example, gray-scale b-mode and motion
(m)-mode US may be used to measure the morphological char-
acteristics of a muscle,63 identify boney changes associated
with lateral epicondylalgia64 or guide an acupuncture needle.45
In contrast, real-time Doppler US allows for dynamic high-res-
olution evaluations of tendon neovascularity.65 Elastography
enables the quantification of the biomechanical properties (ie,
stiffness) of soft tissues (eg, muscle, tendon, ligament) and
subsequently may have a role in assessing the effectiveness of
physical therapy interventions31 54 or stages of tissue healing.66
Implications for scope of practice, regulation and
training
In addition to a lack of regulatory oversight, surveys conducted
in the UK,67 Australia68 and New Zealand41 demonstrate
that there is no internationally accepted curricula for phys-
ical therapists training in US, with continuing education or
3
 Consensus statement
mentoring opportunities varying widely across countries, and
no minimal competency required for using US for patient care.
One explanation for these gaps is that unlike diagnostic and
interventional US, RUSI is a relatively new application and
one that sits almost entirely within the scope of the physical
therapy profession (sports scientists, sport therapists and oste-
opaths also perform RUSI applications). Faced with the rapid
growth of US use by physical therapists over the last decade,
the profession is faced with a situation in which its traditional
scope is being challenged to evolve. Clear and consistent guid-
ance from regulatory and professional associations could assist
in mitigating these gaps and confusion.
Each category of physical therapy US is associated with
unique knowledge, skill sets and potential for perceived
infringement with the scope of other healthcare practitioners.
Although there is some foundational overlapping concepts,
the issues and barriers associated with specialised training,
competent use and reporting of these applications differ. In
the fields of diagnostic and interventional US, there are estab-
lished criteria for training, competent use and regulation, as
outlined by the WHO,69 and international oversight from the
World Federation for Ultrasound in Medicine and Biology.
Physical therapists wanting to become skilled in the use of
diagnostic and interventional US can access training through
existing channels consistent with these standards. With that
said, it is acknowledged that in some countries there may be
limited access to these established training pathways afforded
to physical therapists, and existing educational models may
not include physical therapy-specific applications. It is also
important to consider that the practice of physical therapists
gaining their US training through courses established for other
healthcare practitioners (eg, radiologists, sport and exercise
medicine physicians, sonographers) may lead to physical ther-
apists operating outside of their professional scope of prac-
tice due to an increased familiarity with non-physical therapy
applications. There is a need for evidence-based diagnostic and
interventional US training programme that meets the unique
needs of physical therapists and highlights the issues associated
with the scope of practice and licensing.
Beyond training, it is important to consider that although
diagnostic and/or interventional US may fall within the scope
of physical therapy (assuming suitable training is obtained) in
some jurisdictions, for the majority this is not the case. Regard-
less of training or expertise, physical therapists should clarify
their scope of practice for these US applications by contacting
their regulatory body prior to performing diagnostic or inter-
ventional US. In many instances, a change in legislation to
extend the scope of physical therapy practice in a jurisdiction
may be required before therapists can use US in this manner.
In contrast to diagnostic and interventional US, and despite
increasing evidence that demonstrates a role for RUSI in phys-
ical therapy, the field of RUSI lacks professional oversight,
standard curriculum and regulation for training. These defi-
ciencies have resulted in a paucity of high-quality, evidence-
based training opportunities; a lack of standardisation in the
performance and reporting of RUSI applications; and a poten-
tial for insufficiently trained operators.41 67 68
A framework for US training for physical
therapists
As competent use of US for point-of-care or research purposes
is not part of an entry to practice skill set, and generally absent
in physical therapy entry-to-practice education programme,
4 Whittaker JL, et al. Br J Sports Med 2019;0:1–7. doi:10.1136/bjsports-2018-100193
Br J Sports Med: first published as 10.1136/bjsports-2018-100193 on 25 April 2019. Downloaded from http://bjsm.bmj.com/ on October 10, 2019 by guest. Protected by copyright.
access to postgraduate education to support safe compe-
tent practice is needed. The sections that follow contain key
competencies, options for delivery and learning objectives
for this training. This content is based on literature review,
and the extensive experience of developing and delivering US
training to physical therapists by the authors, in conjunction
with consultation and collaboration with numerous medical
and sonographic professionals and professional organisations
(eg, the British Medical Ultrasound Society), over the last 30
years. The intent of this material is to provide a foundation for
individuals and organisations developing or evaluating RUSI,
diagnostic or interventional US courses for physical therapists.
Core competencies for US use by physical therapists
The Canadian National Physiotherapy Advisory group defines
an essential competency as the repertoire of measurable knowl-
edge, skills and attitudes required by a physical therapist
throughout their professional career.70 For physical therapists
that use US in their practice, this includes the knowledge, skills
and attitudes associated with safe, competent conduct and
interpretation of US examinations. Fundamental competencies
that span all uses of US by physical therapists and those unique
to RUSI, diagnostic, interventional or research US examina-
tions are outlined in Box 1.
Delivery format
Given that physical therapists who utilise US must demonstrate
common fundamental and application-specific competencies,
a competency-based education model of training is suggested.
Competency-based education is driven by the ‘product’
rather than the process,71 72 whereby learning outcomes are
first identified and the curriculum is built in discrete ‘steps’
to ensure that students achieve the competencies described in
the learning outcomes. In the case of US, ‘steps’ could take
the form of an ‘introductory’ (ie, fundamental knowledge
and proficiency) module followed by completion of one, or
several, ‘application-specific’ modules (ie, RUSI, diagnostic or
interventional). The delivery of each module could take the
form of didactic and/or practical instruction with each culmi-
nating in a practical examination of safety, technical aspects,
and image generation and interpretation competence. This
approach allows flexibility for the addition of future US appli-
cations and could be supplemented with formal or informal
mentorship, supervision and case-based examination. In addi-
tion to instruction by physical therapists who are experts in this
field, training should, where possible, involve other imaging
disciplines (eg, sonographer/radiologist/interventional radiol-
ogists) and focus on the pathologies and disorders that phys-
ical therapists treat. Furthermore, it is important to consider
that training could be provided in many settings (eg, entry and
post-professional level) and through different delivery mech-
anisms (eg, pre-reading and exams, online resources, practical
courses, virtual mentoring and supervised scanning or review
of stored images or real-time clips for quality assurance, etc).
There may also be value in embedding training within existing
coursework in entry-to-practice programme (eg, electrophys-
ical agents, anatomy, orthopaedics, neurology, professional
issues courses or yearly or programme-end capping exercises).
Curriculum
The competent conduct and interpretation (including back-
ground knowledge) of US examinations vary by the level of
operator skill (eg, introductory vs advanced) and application
 Consensus statement

Br J Sports Med: first published as 10.1136/bjsports-2018-100193 on 25 April 2019. Downloaded from http://bjsm.bmj.com/ on October 10, 2019 by guest. Protected by copyright.
Box 1. Summary of fundamental competencies Box 1  Continued
(knowledge, skills and attitudes) for safe and efficacious
use of US by physical Therapists* *It is recommended that all physical therapists that use US meet the
fundamental competencies followed by one of the application specific
Fundamental Knowledge, Skills, Attitudes competencies.
RUSI, rehabilitative ultrasound imaging; US, ultrasound.
►► Professional and ethical considerations
►► Communication
►► Basic anatomy and physiology
►► US basic physics (eg, RUSI, diagnostic, interventional, research). Suggested
►► US safety, upkeep and hygiene learning outcomes for ‘introductory’ and ‘application’
►► Basic US terminology and instrumentation modules or courses are outlined in online supplementary table
►► Basic US image generation and optimisation 2 located in.
►► Basic US interpretation including artefact
RUSI Competencies Knowledge, Skills, Attitudes Recommendation and future directions
►► Physical therapy scope and history of RUSI Future efforts should focus on developing international stan-
►► Detailed anatomy and physiology dards for self-governance of US use by physical therapists
►► Theoretical foundations of neuromuscular function and and ensuring that training and practice standards are identi-
dysfunction fied, reached and maintained. Failure to do this may result in
►► RUSI terminology and instrumentation restricted use of US by physical therapists in various jurisdic-
►► RUSI image generation and optimisation tions. Greater interprofessional exposure to the use of US by
►► RUSI interpretation physical therapists is needed to avoid inaccurate assumptions
►► Special issues for specific body regions and applications about professional infringement and to foster understanding
►► Integration of RUSI findings for prevention and management of the unique applications of US that occur within physical
of clinical conditions therapy practice. Finally, it is imperative that physical ther-
►► Evaluate the use of RUSI in clinical practice apists continue to provide evidence that US enhances the
Diagnostic US Knowledge, Skills, Attitudes quality, effectiveness (including cost) and efficacy of physical
►► Physical therapy scope and history of diagnostic US therapy management.
►► Detailed anatomy and physiology
►► Theoretical foundations of pathoanatomical and Author affiliations
1
biopsychosocial models of pain Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of
Alberta, Edmonton, Alberta, Canada
►► Diagnostic US terminology and instrumentation 2
Health and Rehabilitation Research Institute, School of Clinical Sciences, Auckland
►► Diagnostic US image generation and optimisation University of Technology, Auckland, New Zealand
►► Diagnostic US interpretation 3
School of Health and Rehabilitation Sciences, The University of Queensland,
►► Integration of diagnostic US for prevention and management Brisbane, Queensland, Australia
4
of clinical conditions Department of Physiotherapy and Performance Science, University College Dublin,
Dublin, Ireland
►► Evaluate the use of diagnostic US in clinical 5
School of Allied Health Sciences, Griffith University, Brisbane, Queensland, Australia
practice 6
Departmento de Enfermeria y Fisioterapia, Universidad de Alcala de Henares,
Interventional US Knowledge, Skills, Attitudes Madrid, Spain
7
►► Physical therapy scope and history of interventional US Departamento de Fisioterapia, Universidad Francisco de Victoria, Madrid, Spain
8
Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
►► Detailed anatomy and physiology 9
School of Health Professions and Rehabilitation Sciences, University of
►► Interventional US safety Southampton, Southampton, UK
►► Interventional US needle guidance principles, methods and
accuracy Acknowledgements  The authors acknowledge Drs C. Calvo-Lobo and A. Garrido-
►► Interventional US terminology and instrumentation Marin for their invaluable efforts and support of the International Symposium hosted
►► Interventional US image generation and optimisation by the Universidad Francisco de Vitoria and the Spanish Society of Ultrasound
in Physiotherapy in Madrid, Spain (2016) as well as the support of the Arthritis
►► Interventional US interpretation
Research UK Centre for Sport, Exercise and Osteoarthritis, and University of Alberta,
►► Integration of interventional US for prevention and Canada.
management of clinical conditions
Contributors  JLW drafted the first version of the manuscript with assistance from
►► Evaluate the use of interventional US in clinical RE and MJS. All authors contributed to discussions leading up to the manuscript,
practice contributed to sections of the manuscript and approved the final version of the
Research US Knowledge, Skills, Attitudes manuscript. MJS, DST, PWH, JH and JLW were involved in the initial meetings to
►► History of physical therapy research using US discuss the standardisation of USI education for physical therapist at the first
international meeting on RUSI in 2006. DST hosted the first international meeting
►► Relevant anatomy and physiology on Rehabilitative Ultrasound Imaging in San Antonio, USA. SFC and JLAB hosted the
►► Research context background knowledge second RUSI meeting in Madrid, Spain.
►► Study design and research methodology Funding  The authors acknowledge the support of the Arthritis Research UK Centre
►► Research US methodology and approaches for Sport, Exercise and Osteoarthritis (grant number 21595).
►► Research US ethics and safety Competing interests  All authors have completed the ICMJE uniform disclosure
►► Research US terminology, instrumentation and forms at www.​icmje.​org/​coi_​disclosure.​pdf.
applications Patient consent for publication  Not required.
►► Research US image generation and optimisation
Provenance and peer review  Not commissioned; externally peer reviewed.
►► Research US interpretation
►► Research US dissemination Open access  This is an open access article distributed in accordance with the
Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits
Continued others to copy, redistribute, remix, transform and build upon this work for any

Whittaker JL, et al. Br J Sports Med 2019;0:1–7. doi:10.1136/bjsports-2018-100193 5

 Consensus statement
purpose, provided the original work is properly cited, a link to the licence is given,
and indication of whether changes were made. See: http://​creativecommons.​org/​
licenses/​by/​4.​0/.
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